Leukemia Texas - Acceptiva

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Leukemia Texas Patient Aid Application 2025-2026

Leukemia Texas aims to fulfill our mission to help Texans beat leukemia through Patient Aid, Research and Innovation!

Due to the high volume of new applications we receive, Leukemia Texas Patient Aid grants are a one time gift.

Patient Information & Assessment of Needs

First Name: *

Last Name: *

Gender: *

Date of Birth: *

Age: *

Are you of Hispanic, Latino, or Spanish origin? *

Race (check all that apply) *Required Question

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Address: *

If awarded funding, this is the address where your check will be mailed. Please notify us if this information changes.

Address 2:

(Apartment, Suite, etc...)

City: *

State / Province: *

Zip Code: *

County: *

Country: *

Primary Phone: *

Secondary Phone:

E-mail: *

Confirmation will be e-mailed to this address.

US citizen or legal resident: *

Have you received aid from Leukemia Texas before? *

If yes, please note the date you last received patient aid

(This information is collected to help as we apply for grant funding and fundraising efforts. It has no bearing on the approval or denial of your application.)

Family Annual Income for the previous year: *

Number of people in household: *

(All adults and children in your home)

Single Parent Household? *

If the patient is a minor these questions are required*

Name of Legal Guardian(s):

Primary Phone:

Secondary Phone:

Email:

Relationship to the Patient:

WHO IS COMPLETING THIS APPLICATION?

Relationship to Patient:

First and Last Name:

Applicant Cell Phone:

Applicant Email:

Attestation of Ongoing Care

A Patient Aid grant is requested from Leukemia Texas for the purpose of ensuring equal access to care which includes: treatments, laboratory testing, physician examinations, counseling and psychosocial support, transportation, and housing for the patient.

The information provided will be verified with the patient’s physician, nurse and/or social worker by a staff member of Leukemia Texas.

Disclaimer: The Attestation of Ongoing Care requires the complete information for two care team members from the physician's office or clinic. Examples, physician, physician assistant, nurse, social worker, financial counselor or other admin within the office.

Name of Hospital/Treatment Center: *

Hospital City: *

Hospital State: *

Leukemia Diagnosis: *

Please list your specific type of leukemia. If you do not have a leukemia dx, you will not be approved.

Number of Visits Per Year: *

Original Date of Diagnosis: *

Treatment Status: (Check all that apply) * Answer Required

Initial Treatment

Maintenance

Remission

Clinical Trial/Experimental Treatment

Transplant (Prep or Post)

Relapse

Date of Replapse

Physician Name and Contact Information

Physician Name: *

Physician Title:

Physician Phone:

Physician Email:

Secondary Contact from the physician’s office or clinic (Social Worker, Nurse, Physician Assistant, etc.)

Provider 2 Name:

Name of Social Worker, Nurse, Physician Assistant, etc.

Provider 2 Title:

Title of Social Worker, Nurse, Physician Assistant, etc.

Provider 2 Phone:

Phone Number of Social Worker, Nurse, Physician Assistant, etc.

Provider 2 E-mail:

Email Address For Your Social Worker, Nurse, Physician Assistant, etc.

Additional Information

(This information is collected to help as we apply for grant funding and fundraising efforts. It has no bearing on the approval or denial of your application.)

Has there been concern that you would run out of food before getting enough money to buy more? *

(In the past 3 months)

Is one or more of your utilities at risk of shut-off? *

Are you current on your car payment and/or insurance? *

Have you experienced an unexpected emergency? *

Such as car repairs, urgent home repairs, divorce, or other unforeseen family dynamics?

Do you have unaffordable child-care costs? *

Do you have unaffordable health insurance premiums & medical expenses? *

Is your phone at risk of shut off? *

Do you have uncovered travel expenses such as transportation, gas, hotels, etc. *

Are you worried or concerned that in the next 2 months you may not have stable housing? *

(Whether you own, rent, or stay in as part of a household.)

Have you relocated homes due to your medical diagnosis? *

If you've re-located for care, what were your previous city and state?

Do you travel more than 50 miles for treatment? *

Does your household receive or is applying for long-term disability benefits? *

Such as Social Security Disability Income (SSDI) or Supplemental Income (SSI)

Describe the circumstance supporting your request for financial assistance

How has the patient (or family) been financially impacted due to the cancer diagnosis?: *

(We encourage you to share as much detail as you feel comfortable with. The more we understand your family’s story and the specific financial challenges you’ve faced, the better we can support you and help share your story forward. )

Patient Certification

I understand and agree that:

I authorize Leukemia Texas and its agents to access and review the information I have submitted herein, including any private or confidential health information. I understand that this information will be used in connection with their assessment of patient aid and potential payment of a patient aid grant. This authorization expires one year from the date of submission unless otherwise agreed.

By checking this box, I hereby authorize the release of information in this application and related to my diagnosis to Leukemia Texas for the purpose of seeking financial assistance. I affirm that all of the information provided in order to qualify for financial assistance is complete and accurate. I understand that I may be denied assistance if any of the above information is false, and that I may be required to repay any assistance that I have received based on false or incomplete information.

Leukemia Texas in its sole discretion shall determine my eligibility, participation and termination in its Patient Aid program.

Leukemia Texas does not guarantee payment of patient aid

Leukemia Texas shall have no liability pursuant to my application, participation, continuation or termination in its Patient Aid program.

I authorize my Physician to release to Leukemia Texas such medical information of mine as it may require to administer my application and participation in its Patient Aid program

If other, please specify:

Photo Consent

We often use photos to help put a face to the stories we share—whether on social media, in our newsletters, or in other communications that highlight the impact of our programs. Seeing the people behind these stories adds a powerful human element and helps others better understand the real lives touched by Leukemia Texas.

(Sharing a photo is completely optional, but it truly helps us tell your story in a more personal and meaningful way.)

You may submit a photograph of yourself or your family to patientaid@leukemiatexas.org

By checking this box, I hereby consent to the use of my photographic image together with my name, age, city of residence, occupation, and type of leukemia for public use by Leukemia Texas, Inc. I further release from liability and hold harmless Leukemia Texas, Inc. in the use of my image and information.